Seeking Zero Defects:

Applying the Toyota Production

System to Medicine
Pay For Performance Summit
March 9, 2010
Gary S. Kaplan, MD, Chairman and CEO
Virginia Mason Medical Center
Seattle, Washington

If you are dreaming about it

you can do it.
Sensei Chihiro Nakao

First, Some Background

Virginia Mason Medical Center

An integrated healthcare system

501(c)3 Not for Profit
336 bed hospital
9 locations (main campus and regional centers)
450 physicians
5000 employees
Graduate Medical Education Program
Research center
Center for Health Care Solutions
Virginia Mason Institute

Time for a Change

Year 2000
Issues

Survival
Retention of the Best People
Loss of Vision
Build on a Strong Foundation

Leadership Change
A Defective Product

Why is Change So Hard?

Culture
Lack of Shared Vision
Misaligned Expectations
No Urgency
Ineffective Leadership

An Embarrassingly Poor Product

The March 16, 2003 edition of The New York Times
Magazine front cover reads, Half of what doctors know
is wrong.
The lead story is titled The Biggest Mistake of Their
Lives and chronicles four survivors of medical errors.
The article goes on to say that in 2003, as many as
98,000 people in the United States will die as a result of
medical errors.

Virginia Mason Medical Center

November 23, 2004
Investigators: Medical mistake kills
Everett woman

Hospital error caused death

Traditional Compact

Despite the fact things werent working, most

physicians clung to the fundamental gets they
felt due them
Protection
Autonomy
Entitlement

Physician-centered world view prevailed

Virginia Mason Medical Center Physician Compact

Organizations Responsibilities
Foster Excellence
Recruit and retain superior physicians and staff
Support career development and professional
satisfaction
Acknowledge contributions to patient care and the
organization
Create opportunities to participate in or support
research
Listen and Communicate
Share information regarding strategic intent,
organizational priorities and business decisions
Offer opportunities for constructive dialogue
Provide regular, written evaluation and feedback
Educate
Support and facilitate teaching, GME and CME
Provide information and tools necessary to improve
practice
Reward
Provide clear compensation with internal and market
consistency, aligned with organizational goals
Create an environment that supports teams and
individuals
Lead
Manage and lead organization with integrity and
accountability

Physicians Responsibilities
Focus on Patients
Practice state of the art, quality medicine
Encourage patient involvement in care and treatment decisions
Achieve and maintain optimal patient access
Insist on seamless service
Collaborate on Care Delivery
Include staff, physicians, and management on team
Treat all members with respect
Demonstrate the highest levels of ethical and professional
conduct
Behave in a manner consistent with group goals
Participate in or support teaching
Listen and Communicate
Communicate clinical information in clear, timely manner
Request information, resources needed to provide care
consistent with VM goals
Provide and accept feedback
Take Ownership
Implement VM-accepted clinical standards of care
Participate in and support group decisions
Focus on the economic aspects of our practice
Change
Embrace innovation and continuous improvement
Participate in necessary organizational change

Our Strategic Plan

The VMMC Quality Equation

Q = A (O + S)
W
Q: Quality
A: Appropriateness
O: Outcomes
S: Service
W: Waste

New Management Method: The Virginia

Mason Production System
We adopted the Toyota Production System philosophies
and practices and applied them to health care because
health care lacks an effective management approach that
would produce:

Customer first
Highest quality
Obsession with safety
Highest staff satisfaction
A successful economic enterprise

Relentless War on Waste:

Key to Quality
7 Wastes:

Waste of overproduction

Lab tests

Waste of transportation

Patient transfers

Waste of over processing

Charge tickets

Waste of inventory

Drugs, supplies

Waste of motion

Searching for charts

Waste of making defective

products or poor quality

Professional liability

Waste of engineering

Large centralized machines

The Impact of Lean

the human effort
the space
the equipment
the inventory
the investment
the engineering hours
the new product development time

Seeing with our Eyes

Japan 2002

Hitachi Air Conditioning

Team Leader Kaplan
reviewing the flow of
the process with
Drs. Jacobs and
Glenn

Summary
How are air conditioners, cars, looms and airplanes like health care?
Every manufacturing element is a production processes
Health care is a combination of complex production processes:
admitting a patient, having a clinic visit, going to surgery or a
procedure and sending out a bill
These products involve thousands of processesmany of them very
complex
All of these products involve the concepts of quality, safety, customer
satisfaction, staff satisfaction and cost effectiveness
These products, if they fail, can cause fatality

VMPS Tools in Action

Value Stream Development

RPIW
5S
3-P
Standard Work
Daily Work Life

(Rapid Process Improvement Workshop)

(Sort, simplify, standardize, sweep, self-discipline)

(Production, Preparation, Process)

5S Anesthesia Shadow Board - Before

5S Anesthesia Shadow Board - After

Central Line Insertion Standard Work

Before

Dry:
30 sec scrub
30 sec dry
Wet:
2 min scrub
1 min dry

Paws

Maximum
Barrier
Protection

OR

AND

Thyroid

Angio Drapes

During

Transducer
Kit in Top
Drawer of
Cart

OR

Transducer Method

Manometer Method

After
Approved to use
Date/Initial

Yellow

top of cart

Complete Paperwork

White

in chart
progress notes

Stopping the Line

Virginia Masons Patient

Safety Alert System

Stopping the line

Patient Safety Alert Process

Created August 2002
Leadership from the top
Drop and run commitment
24/7 policy, procedure, staffing
Legal and reporting safeguards

Patient Safety Alert Results

as of December 31, 2009
14,604 Patient Safety Alerts

Diagnosis/Treatment
Medication Errors
Systems
Equipment/Facilities
Safety/Security/Conduct

Average # of PSAs/month

2002- 3/month
2003- 10+/month
2004- 17/month
2005- 251/month
2006- 276/month
2007 -238/month
2008 - 226/month
2009 - 244/month

25%
21%
36%
4%
14%

Primary Care Flow Stations

VMPS Concepts of a Flow Station

URGENT

Waste of motion (walking)

Continuous flow
Visual control (Kanbans)

PAPER
MAIL

External setup

CERNER
MESSAGE

Water strider
U-Shaped Cell
RESULT
REPORT

DOCUMENT
VISIT
$
CHARGE
SLIP
$

Creating MD Flow Reduces Patient Wait Times

Nursing Cells Results > 90 days

RN time available for patient care = 90%!
Before
RN # of steps = 5,818
PCT # of steps = 2,664
Time to the complete am cycle of work = 240
Patients dissatisfaction = 21%
RN time spent in indirect care = 68%
PCT time spent in indirect care = 30%
Call light on from 7a-11a = 5.5%
Time spent gathering supplies = 20

After
846
1256
126
0%
10%
16%
0%
11

Improving Quality and Access:

Emergency Department
2008Hrs

250

2009Hrs

Total2009Hours:113.92

200
150
100

Total2008 Hours:696.97
50
0
Jan
2008
Hrs.
2009
Hrs.

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

191.25

95.55

130.5

68

64.9

59.25

18.75

28

11.3

13.55

6.37

9.55

7.5

11.07

16.97

8.4

18.78

6.1

14.68

14.02

16.4

Dec

Lindeman Surgery Center

Throughput Analysis

Before
Time Available 600 min

Today
600 min

% Change
0%

(10 hr day)

Total Case Time 107 min

65.5 min

39%

15 min

50%

(cut to close plus set-up)

Case Turnover
Time (pt out to pt in)

Cases/day

Cases/4 ORs

30 min

(ability to be <10 min)

5 cases/OR
20 cases

8 cases/OR

60%

32 cases

60%

Patient&StaffSatisfactionCorrelation

Successful Economic Performance

$ (Millions)

Shared
Success
Program
Threshold

Hospital Acute LOS

Lead Time Reduction
Hospital Monthly Acute LOS
LOS

Linear (LOS)

4.80
Focus on
ELOS

RN Cell
Established

4.60

ELOS
RPIW #1
High
Risk ID

RN Bedside
Handoff

2 Bin
System

CCU ELOS
RPIW

Mobility
RPIW

4.40

RN/PCT Skill
Task
Alignm ent

ELOS
RPIW #2
SNF and
Greater than

4.20

CNL Role
Im plem ented

4.00
Palliative Care
Program Started

On Line SNF
Request

Nutrition
RPIW

3.80
Lead Tim e Reduction
Declared as Divsional Goal

ELOS #3
Care Team

3.60

CCU ELOS
KAIZEN

Target ELOS floors

Kaizen Plan and CNL

CNL/MSW
Handoff

3.40
Jun- Jul-05 Aug05
05

Sep05

Oct05

Nov05

Dec05

Jan06

Feb06

Mar06

Apr06

May06

Jun- Jul-06 Aug06

06

Sept.
06

Oct.
06

Nov.
06

Dec.
06

Jan.
07

Feb07

Mar07

Apr07

May07

Jun- Jul-07 Aug07

07

Requirements for Transformation

Improvement Method
Applied to ALL Processes

Critical mass
feels urgency for
change

Executives address
technical AND
human dimensions
of change

Visible and committed

leadership

Broad and deep

commitment to
shared vision

New compact
aligns expectations
with vision

Virginia Mason Medical Center

Leadership Compact
Foster Excellence
Recruit and retain the best people
Acknowledge and reward contributions to patient care and the organization
Provide opportunities for growth of leaders
Continuously strive to be the quality leader in health care
Create an environment of innovation and learning

Focus on Patients
Promote a culture where the patient comes first in everything we do
Continuously improve quality, safety and compliance

Lead and Align

Create alignment with clear and focused goals and strategies
Continuously measure and improve our patient care, service and efficiency
Manage and lead organization with integrity and accountability
Resolve conflict with openness and empathy
Ensure safe and healthy environment and systems for patients and staff

Promote Team Medicine

Develop exceptional working-together relationships that achieve results
Demonstrate the highest levels of ethical and professional conduct.
Promote trust and accountability within the team

Listen and Communicate

Share information regarding strategic intent, organizational priorities, business
decisions and business outcomes
Clarify expectations to each individual
Offer opportunities for constructive open dialogue
Ensure regular feedback and written evaluations are provided
Encourage balance between work life and life outside of work

Listen and Communicate

Communicate VM values
Courageously give and receive feedback
Actively request information and resources to support strategic intent,
organizational priorities, business decisions and business outcomes

Educate
Support and facilitate leadership training
Provide information and tools necessary to improve individual and staff
performance

Take ownership
Implement and monitor VM approved standard work
Foster understanding of individual/team impact on VM economics
Continuously develop ones ability to lead and implement the VM Production
System
Participate in and actively support organization/group decisions
Maintain an organizational perspective when making decisions
Continually develop oneself as a VM leader

Recognize and Reward

Provide clear and equitable compensation aligned with organizational goals and
performance
Create an environment that recognizes teams and individuals

Foster Change and Develop Others

Promote innovation and continuous improvement
Coach individuals and teams to effectively manage transitions
Demonstrate flexibility in accepting assignments and opportunities
Evaluate, develop and reward performance daily
Accept mistakes as part of learning
Be enthusiastic and energize others

Leaders Role in Signal

Generation
Leaders are signal generators who reduce
uncertainty and ambiguity about what is
important and how to act.
Charles OReilly III

OR

Tuesday Stand Up

Distress and Adaptive Work

Disequilibrium

Adaptive challenge

Limit of tolerance

Productive range
of distress

Threshold of
learning
Time
Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, 2002, p 108

Flu Vaccination Fitness for Duty

Do we put patient first?

Compelling science
Staff resistance
Staying the course
Organizational Pride

98.00%

100%
90%

98.50%

99.00%

99.25%

80%
70%

54.00%

60%
50%
40%

38.00%
29.50%

30%
20%
10%

Year

20
08

20
07

20
06

20
05

20
04

20
03

0%

20
02

Percent of Employees Immunize

Figure 1: Immunization Rates

We are Eight Years into the Journey

2002 - 2004

2005 - 2006

2007 present

2009

Ongoing Challenges - Culture

Patient First
Belief in Zero Defects
Professional Autonomy
Buy In

Pace of Change
Victimization
Leadership Constancy
Rigor, Alignment,
Execution

People are Not Cars

Drive for Results

First Challenge is Changing the Mind of Medicine

FROM

Provider First
Waiting is Good
Errors are to be Expected
Diffuse Accountability
Add Resources
Reduce Cost
Retrospective Quality Assurance
Management Oversight
We Have Time

TO

Patient First
Waiting is Bad
Defect-free Medicine
Rigorous Accountability
No New Resources
Reduce Waste
Real-time Quality Assurance
Management On Site
We Have No Time

LEADERSHIP MUST CHANGE ITS MENTALITY.

SCARCITY:
You are not paying us enough.

ABUNDANCE:
We have more than enough.

Leaders are Dealers

in Hope.
Napoleon Bonaparte

In times of change,
learners inherit the
earth, while the learned
find themselves
beautifully equipped to
deal with a world that
no longer exists.
Eric Hoffer

Copyright 2009VirginiaMasonMedicalCenter.AllRightsReserved.